Newsletter Vol.2 #1


As we start a new year, century and millenium, it is only fitting that we start on the credentialing of new applicants and re-credentialing of present medical staff members.

Credentialing is a process of determining whether or not an applicant has the general qualifications for your medical staff and consists of three parts.  The first is the applicant or re-applicant requesting the application, filling it out completely and truthfully with all references and returning it to the Medical Staff Office.  The second is the verification of all required material by the Medical Staff Office.  The third and last step is the internal process of reviewing, with or without interviewing the applicant, and recommending to the governing body (Board) the medical staff decision regarding the applicant.  The Board makes the final decision regarding medical staff credentialing.  This process is tied to, but is not the same as, privileging.  Privileging is qualification for specific types of procedures or patients.

Hospital membership is a privilege and not a right.  Credentialing of applicants and re-applicants are to protect patient care.  If a person holds a license to practice medicine in California, he/she is not automatically entitled to medical staff membership.  The burden is on the applicant to furnish the evidence required for medical staff membership not on the medical staff office to continue to remind the applicant or re-applicant.

The initial credentialing packet is sent to and received from the applicant by the Medical Staff Office.  If it is a new application, it can be handled in either the standard manner or under a “fast track” methodology. This new way allows the application to be reviewed expeditiously.  If there are no “red flags”, the application is screened by the Department Chair, Credential Chair, and Chief of Staff and then sent to the Board.  If there is any doubt by any level of review, the application is handled in the standard manner.  The “red flags” for initial appointment include but are not limited to time lapses in training, “iffy” letters of recommendations, or out of training for a period of time and not Board Certified or Eligible.  The criteria for membership are set in advance for all applicants by the medical staff. This will help alleviate any potential antitrust action. There is a potential for a lack of checks and balances with the fast track system where a powerful physician  may intercede to let a non-qualified applicant on the staff. This has apparently happened on at least one occasion. There have been some recent JCAHO Type I recommendations given for using this system. (Since this was written the JCAHO rules have changed to allow fast track as long as a board committee and not just one person approves the applicant on an expedited basis.) 

The standard method is the application goes through committees and not just chairs.  This requires more time for the committees to meet, but does allow for more medical staff members to “eyeball” the application. There are now some new web based technologies that may help speed up the standard credentialing process. The applicant should not be given even temporary staff membership until the Medical Staff Office verifies all the basic information and all fees paid.

Many medical staffs for an initial applicant use a “pre-application” or a letter explaining the medical staff’s pre-determined minimum objective standards for membership.  If the pre-applicant answers the questions falsely, does not answer the questions or does not have the general qualifications required for staff membership they may be rejected and not be entitled to a Judicial Appeal.  If they pass the pre-application and the application is then denied, the affected physician is entitled to a Judicial Review on the reasons for the denial. This will be expensive for both parties.  If they are kept off for competitive reasons, unless exclusive contracts exist, antitrust concerns may be raised. It is imperative that medical staffs follow their by-laws exactly or they may be sued for membership.  The Health Care Quality Improvement Act (HCQIA) allows an antitrust suit but not monetary damages. The courts may allow an injunction against the medical staff and hospital allowing the applicant on the staff. They may also allow attorney’s fees, which may be considerable.  Please consult your independent medical staff attorney (paid by the medical staff, not the hospital).  

The rule for re-application to the medical staff is that it must be done every two years.  The Joint Commission is very tough on this.  If only one person is not re-credentialed for any reason by the Board within the allotted time, a Type I violation may ensue. I suggest that re-appointment packets be sent out well in advance (3-4 months) of the date needed.  It takes considerable time for the information to be verified, letters of recommendation received and the slow processes of going through the Department, Credential and Medical Executive Committees prior to Board action. If an applicant is not through the whole credentialing process due to no fault of the applicant in the allotted time temporary privileges may be granted.  This does not take the place of the formal recredentialing process.

Economic credentialing, as defined as credentialing for economic reasons unrelated to quality or competence, is frowned on by most medical societies. However, where a physician uses more resources than others, it is possible that they have less clinical skills and need to be watched closely by the medical staff.

At the time of both initial application and reapplication the Medical Board of California, National Practitioner Data Bank must be queried.  Other queries are for DEA license, Medicare sanctions, and malpractice insurance. Some hospitals even hire firms to look for any medically related crimes.  References from peers are imperative.  These should include one from a medical staff member in the same field who is not in business with the applicant. An MD and DO may give references for each other but a DDS or DPM etc. need to be peer referenced.  CME is required by the State for licensure and the Joint Commission wants to see that the Medical Staff has asked as well.  This may be done by having the physician bring in proof of all CME or by merely attesting that he/she has enough hours to qualify.  If the latter is chosen, random audits should be done. The educational hours do not have to be in the person’s specialty.

The application and re-application questionnaire should address all the above areas plus Board Certification status, whether the applicant has been convicted or is being investigated for Medicare or Medicaid fraud and any health issues that may preclude the practitioner from performing their clinical duties.

COMPLETE credentialing should be performed for ALL medical staff applicants. If you believe that you can let one application slide, I recommend highly the book Blind Eye that describes how a physician was not credentialed properly.  Dr. Swango, the physician in the book, is currently in jail.  He is possibly tied to murders of patients.

The credentialing process and its timeline make an excellent continuous quality improvement project.  This may also save the Medical Staff a Type I recommendation from JCAHO.

If your hospital allows Allied Health Professionals (AHP), they should be credentialed in the same manner as the medical staff.  Again, references from supervising people are important. The question is who should oversee the process, the Medical Staff or the Hospital.  If the AHP is hired (employed) by the hospital, the hospital should do the credentialing.  If the AHP perform clinical work as Licensed Independent Practitioners, they may be monitored via the Medical Staff. This is an ongoing controversy.  It is possible that those physicians doing peer review on AHPs will not be afforded the protections of the Health Care Quality Improvement Act. A Committee on Interdisciplinary Practice as required under Section 70706 of Title 22 is a non-medical staff committee that reports to the Board. Physicians on this committee will probably be protected under the hospital umbrella.

Please contact me if there are any topics you wish me to discuss in future editions or if I may be of service to you and/or your Medical Staff.  If you are no longer the Chief of Staff, please forward this newsletter to that individual.  I would  appreciate if you would ask your Medical Staff Office to send me the correct name of the new Chief of Staff. Thank you and I hope your new year is filled with health and happiness.

DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the time of publication. Nothing in this article constitutes legal advice. Readers should consult with their own legal counsel before acting on any of the information presented.